SEMM Testing Application

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Fill out this application onscreen and print with your browser.

Name:
Birthdate:  
Address:
City: State:   ZIP Code: 
Daytime Phone: Evening Phone: 
Email Address:  

Please check the appropriate box(es):

    
$18 US Mensa Home Test -- payable to Southeast Michigan Mensa
$40 US Mensa Admissions Test -- payable to American Mensa, Ltd.
      a) Second Saturday of the month in Plymouth
  OR  
      b) By appointment -- Select a location:
Ann Arbor Plymouth
Downriver Sterling Heights
Flint Southfield
Grosse Pointe    
 
          If you would prefer a non-verbal test, please check here
and also indicate which location you would prefer.
$40 US Culture Fair Mensa Admissions Test -- payable to American Mensa, Ltd.
 By appointment only 

Home Test fees should be payable to: Southeast Michigan Mensa
Mensa Admissions Test fees should be payable to: American Mensa, Ltd.
If ordering both the Home Test and the Admissions Test, you will need to write two separate checks.
Return this form and your check(s) to:    
  Pauline Averbach
2378 22nd Street
Wyandotte, MI 48192